Julia Kim School of Public Health University of the Witwatersrand & Health Policy Unit

1. The IMAGE Program in South Africa: Taking a “Structural” Approach to HIV Prevention through Cross-Sectoral NGO Partnerships Julia Kim School of Public Health University of the Witwatersrand & Health Policy Unit London School of Hygiene & Tropical Medicine PONPO, Yale University Apr 14, 2009

2. “Despite broad recognition that underlying social conditions - including poverty & gender inequalities - affect vulnerability to HIV infection, there is a serious deficiency in the design and testing of interventions to critically engage issues at this level” Track D Summary XIth International AIDS Conference Vancouver, 1996 (Mane, Aggleton, Dowsett et al)

3. Prevailing Approaches to HIV Prevention Risk factor epidemiology & “individual risk” ? Psychological models of behaviour change (e.g.Theory of reasoned action) Abstinence Partner reduction Condom use Primarily technical & health sector driven

4. Structural determinants & HIV/AIDS “Upstream” factors that impact on individual behaviour change Poverty & economic inequalities Overlapping & mutually reinforcing Individual Behaviour Mobility & migration Gender Inequalities Impact both developed & developing countries

5. Structural Interventions… Work by altering the context in which health is produced- Blankenship et al, AIDS 2000 Target Populations rather than individuals Socio-economic conditions Individual Behaviour Multiple Levels for intervention Cultural Norms Laws & Policies Evolving field: little research in developing countries

6. The IMAGE Study:A structural intervention to address HIV and Gender-based violence in South Africa Microfinance Poverty & economic inequalities IMAGE Gender violence HIV infection Gender /HIV training Gender Inequalities

7. The IMAGE Study (Intervention with Microfinance for AIDS and Gender Equity) • Microfinance NGO: Small Enterprise Foundation • Women’s businesses: Selling produce, clothes, food stalls • HIV Training: RADAR • 1-hr sessions during loan repayment meetings q. 2 weeks • 6 month structured curriculum • 6 month community mobilization: Village Action Plans around GBV and HIV

8. Evaluation: Cluster- Randomized Trial 2001-2004 • 8 villages in rural Limpopo (pop 64, 000) • Matched on size and accessibility • Randomly selected (Control villages receive intervention at end of study) • Intervention + control participants • Matched by age and poverty-status • Face-to-face interviews: Baseline and 2 years later • Analysis: Adjusted for baseline differences and village-level clustering • Parallel qualitative research • 3 full-time anthropologists

9. Results: Impacts on Poverty & Women’s Empowerment - JC Kim et al. AJPH 97 (10), Oct 2007 Economic well-being: • Improved food security, household assets Women’s empowerment: • Greater self confidence, autonomy, challenging gender norms, collective action: • 5 public marches • 40 village workshops • 16 meetings with local leaders • 2 new village committees target Crime and Rape

10. Intimate partner violence • After 2 years, past year risk of physical & sexual violencereduced by 55% (aRR 0.45 95% CI 0.23-0.91) • HIV Risk* • Among young IMAGE participants (age<35): • Increased HIV communication aRR=1.46 (1.01 – 2.12) • Increased VCTaRR=1.64 (1.06 – 2.56) • Reducedunprotected sexwith non-spousal partner by 24% aRR = 0.76 (0.60 – 0.96) * Pronyk et al. AIDS 22, 2008

11. Emerging Lessons… • It is possible to address GBV as part of HIV prevention, and to do so within project timeframes • Challenges belief that gender norms & GBV “culturally entrenched” and resistant to change • Cross-sectoral interventions can generate synergy Microfinance: Meeting “basic needs” as part of HIV prevention • piggy-backing onto MF program: sustained participation Health Training: Empowerment about “more than just money” MF Alone Study: MF (without training) improved poverty but did NOT lead to broader impacts (empowerment, IPV, HIV risk) • Importance of education, addressing social norms & community mobilisation (Kim et al. Bulletin of WHO, 2009) Strong partnerships models: each stick to what you do well • Loan repayment rates 99%

12. IMAGE: Scaling up in South Africa Pilot Study Additional cost = US $43/client Scale-up Additional cost = US $13/client 2001-2004 2005-2007 2008-2010 430 households 4500 households (30,000) 15 000 households (80,000)

13. From Micro to Macro: Linking Programs to Supportive Policy Environment • Individual programs on their own, unlikely to impact on poverty or HIV on a national scale • MF a “foothold” out of poverty, but not the whole ladder… • However such programs do: • Demonstrate feasibility & suggest pathways for affecting health outcomes • Yield practical lessons & cross-sectoral partnership models • Provide “metaphor” for what might be possible by combining economic empowerment & HIV prevention on wider scale

14. Scaling up “principles” as well as programs Not just about scaling up programs(MF,Gender) but impetus for wider policy change Country level: National AIDS Strategic Plans Rural economic development Girls’ education Domestic violence legislation Customary Laws & women’s legal status

15. Policy implications: At country level: How to begin addressing structural factors as part of national HIV/AIDS strategy? SA National HIV/AIDS Strategic Plan (2007-2011): • Goal 18: Focus on the human rights of women and girls and mobilize society to stop gender-based violence and advance equality in sexual relationships • Objective 1.2: Roll-out integrated microfinance and gender education interventions starting in the poorest and highest HIV burden areas “Mainstreaming AIDS in Development” (UNDP/UNAIDS) • Role of donors & government sectors in supporting structural approaches to HIV (e.g. integrating Gender/HIV into economic development programs) • Private sector: Beyond “corporate social responsibility” (e.g. Anglo Platinum Mines, Goldman Sachs 10,000 Women Campaign)

16. Structural interventions & HIV Prevention:An unexplored frontier… • Microfinance & HIV • IMAGE (S Africa) • TRY (Kenya) • SHAZ (Zimbabwe) • Masculinities & HIV: • Promundo (Brazil, India) • Men as Partners (SA) Socio-economic conditions Individual Behaviour • Women’s property & inheritance laws • ICRW review (2004) Cultural norms Laws & Policies

17. Early in epidemic Attention to structural drivers in North as well as South Calls to address structural factors 1990s: Prevention “burnout” Side-tracked by ideological “ABC” debates Great hopes placed in ART & new prevention “technology” (PrEP, male circumcision, microbicides, vaccines) No “magic bullets” 2000s: Learning from the past? Structural interventions: time to “enrich the mix” of prevention strategies 25 years into the AIDS Pandemic… The “AIDS Pendulum” Treatment Prevention

18. A “slow motion tsunami” Requires both: Immediate, “AIDS-specific” responses (e.g. ART)AND Long-term commitment to addressing structural factors as part of Prevention The challenge: Can we combine sense of urgency with long-term vision? AIDS is a long-wave event… “Make haste slowly” - Milarepa (12th Century, Tibet)

19. Acknowledgements LSHTM & WITS colleagues: • Paul Pronyk, Charlotte Watts, James Hargreaves, Lulu Ndhlovu, Godfrey Phetla, Linda Morison, Joanna Busza, John Porter. Funders: • South African Department of Health, DFID, SIDA, HIVOS, Ford Foundation, AngloPlatinum & The AngloAmerican Chairman’s Educational Trust & Kaiser Family Foundation